197609921-1-7-2024-31-AS-JGTN-CZA2L9-20240107162909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609921
Report Date: 01/07/2024
Date Signed: 01/07/2024 04:30:00 PM

Document Has Been Signed on 01/07/2024 04:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SERENITY SENIOR RETREAT		FACILITY NUMBER:	197609921
ADMINISTRATOR:	PERERA, JILSKA		FACILITY TYPE:	740
ADDRESS:	26213 BEECHER LANE		TELEPHONE:	(661) 313-3030
CITY:	STEVENSON RANCH	STATE: CA	ZIP CODE:	91381
CAPACITY:	6	CENSUS: 4	DATE:	01/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Errol Fernando - Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan, met with co administrator Errol Fernando for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:52 PM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying four (4) residents. The facility is fire cleared for three (3) non-ambulatory residents one (1) of which may be bedridden on Room #1 and three (3) ambulatory. Hospice waiver for six (6) residents Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and last inspected on 07/25/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SERENITY SENIOR RETREAT	FACILITY NUMBER: 197609921
	VISIT DATE: 01/07/2024

NARRATIVE

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(continued on LIC 809-C)

The garage is attached to the house. The garage is currently being used as staff rest area and storage for old equipment, frozen foods, PPE and other toxins. Laundry room is located on a small room on the way to the garage, Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. The laundry room was observed to be locked during visit. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 112.5°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the dining area cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located in the medication cabinet.

Client records: Client records are reviewed. Residents record appeared to be complete and current.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 11/28 /23. Required posting observed in facility (complaint hot line poster).

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2024

LIC809 (FAS) - (06/04)

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